LCD/NCD Portal
Automated World Health
L29202
INTERFERON
10/01/2011
Indications and Limitations of Coverage and/or Medical Necessity
Interferon beta-1a (Q3025)
• Medicare will consider the administration of Interferon beta-1a medically reasonable and necessary for the following indication:
o Multiple sclerosis.
Interferon alfacon-1 (J9212)
• Medicare will consider the administration of Interferon alfacon-1 medically reasonable and necessary for the following indications:
o chronic hepatitis C
o Hairy cell leukemia.
Interferon alfa-2B (J9214)
• Medicare will consider the administration of Interferon Alfa-2B medically reasonable and necessary for the following indications:
o acute or chronic hepatitis C,
o chronic hepatitis B,
o condylomata acuminata,
o hairy cell leukemia,
o malignant melanoma,
o AIDS-related Kaposi’s sarcoma,
o head and neck cancer,
o bladder cancer,
o brain cancer,
o carcinoid syndrome,
o chronic lymphocytic leukemia,
o chronic myelocytic leukemia,
o cutaneous T-cell lymphoma,
o esophageal cancer,
o renal cancer,
o multiple myeloma,
o non-Hodgkin’s lymphoma,
o mycosis fungoides,
o essential thrombocytosis,
o essential thrombocythemia,
o osteosarcoma,
o ovarian cancer,
o pancreatic cancer,
o skin cancer,
o colorectal cancer,
o polycythemia vera
o Laryngeal papillomatosis.
• Medicare will consider the administration of Interferon Alfa-2B medically necessary for the off-label indication of:
o Peritoneum cancer.
Interferon alfa-N3 (J9215)
• Medicare will consider the administration of Interferon alfa-N3 medically reasonable and necessary for the following indications:
o chronic hepatitis C,
o condylomata acuminata,
o hairy cell leukemia,
o malignant melanoma,
o AIDS-related Kaposi’s sarcoma,
o bladder cancer,
o carcinoid syndrome,
o chronic myelocytic leukemia,
o renal cancer,
o multiple meyloma,
o non-Hodgkin’s lymphoma,
o mycosis fungoides,
o essential thrombocytosis,
o ovarian cancer
o Laryngeal papillomatosis.
• Medicare will consider the administration of Interferon alfa-N3 medically necessary for the off-label indication of:
o Peritoneum cancer.
Interferon gamma-1B (J9216)
• Medicare will consider the administration of Interferon gamma-1B medically reasonable and necessary for the following indications:
o Chronic granulomatous disease.
Limitations:
• The self-administration of Interferons alfacon-1, alfa-2B, alfa-N3, and gamma-1B are noncovered by Medicare.
CPT/HCPCS Codes
J9212 INJECTION, INTERFERON ALFACON-1, RECOMBINANT, 1 MICROGRAM
J9214 INJECTION, INTERFERON, ALFA-2B, RECOMBINANT, 1 MILLION UNITS
J9215 INJECTION, INTERFERON, ALFA-N3, (HUMAN LEUKOCYTE DERIVED), 250,000 IU
J9216 INJECTION, INTERFERON, GAMMA 1-B, 3 MILLION UNITS
Q3025 INJECTION, INTERFERON BETA-1A, 11 MCG FOR INTRAMUSCULAR USE
ICD-9 Codes that Support Medical Necessity
For Q3025 (Interferon beta-1a):
340 MULTIPLE SCLEROSIS
For J9212 (Interferon Alfacon-1):
070.54 CHRONIC HEPATITIS C WITHOUT HEPATIC COMA
202.40 LEUKEMIC RETICULOENDOTHELIOSIS UNSPECIFIED SITE
202.41 LEUKEMIC RETICULOENDOTHELIOSIS INVOLVING LYMPH NODES OF HEAD FACE AND NECK
202.42 LEUKEMIC RETICULOENDOTHELIOSIS INVOLVING INTRATHORACIC LYMPH NODES
202.43 LEUKEMIC RETICULOENDOTHELIOSIS INVOLVING INTRA-ABDOMINAL LYMPH NODES
202.44 LEUKEMIC RETICULOENDOTHELIOSIS INVOLVING LYMPH NODES OF AXILLA AND UPPER ARM
202.45 LEUKEMIC RETICULOENDOTHELIOSIS INVOLVING LYMPH NODES OF INGUINAL REGION AND LOWER LIMB
202.46 LEUKEMIC RETICULOENDOTHELIOSIS INVOLVING INTRAPELVIC LYMPH NODES
202.47 LEUKEMIC RETICULOENDOTHELIOSIS INVOLVING SPLEEN
202.48 LEUKEMIC RETICULOENDOTHELIOSIS INVOLVING LYMPH NODES OF MULTIPLE SITES
For J9214 (Interferon alfa-2B):
070.41 ACUTE HEPATITIS C WITH HEPATIC COMA
070.44 CHRONIC HEPATITIS C WITH HEPATIC COMA
070.51 ACUTE HEPATITIS C WITHOUT MENTION OF HEPATIC COMA
070.54 CHRONIC HEPATITIS C WITHOUT HEPATIC COMA
070.59 OTHER SPECIFIED VIRAL HEPATITIS WITHOUT HEPATIC COMA
078.11 CONDYLOMA ACUMINATUM
140.0 MALIGNANT NEOPLASM OF UPPER LIP VERMILION BORDER
140.1 MALIGNANT NEOPLASM OF LOWER LIP VERMILION BORDER
140.3 MALIGNANT NEOPLASM OF UPPER LIP INNER ASPECT
140.4 MALIGNANT NEOPLASM OF LOWER LIP INNER ASPECT
140.5 MALIGNANT NEOPLASM OF LIP UNSPECIFIED INNER ASPECT
140.6 MALIGNANT NEOPLASM OF COMMISSURE OF LIP
140.8 MALIGNANT NEOPLASM OF OTHER SITES OF LIP
140.9 MALIGNANT NEOPLASM OF LIP UNSPECIFIED VERMILION BORDER
141.0 MALIGNANT NEOPLASM OF BASE OF TONGUE
141.1 MALIGNANT NEOPLASM OF DORSAL SURFACE OF TONGUE
141.2 MALIGNANT NEOPLASM OF TIP AND LATERAL BORDER OF TONGUE
141.3 MALIGNANT NEOPLASM OF VENTRAL SURFACE OF TONGUE
141.4 MALIGNANT NEOPLASM OF ANTERIOR TWO-THIRDS OF TONGUE PART UNSPECIFIED
141.5 MALIGNANT NEOPLASM OF JUNCTIONAL ZONE OF TONGUE
141.6 MALIGNANT NEOPLASM OF LINGUAL TONSIL
141.8 MALIGNANT NEOPLASM OF OTHER SITES OF TONGUE
141.9 MALIGNANT NEOPLASM OF TONGUE UNSPECIFIED
142.0 MALIGNANT NEOPLASM OF PAROTID GLAND
142.1 MALIGNANT NEOPLASM OF SUBMANDIBULAR GLAND
142.2 MALIGNANT NEOPLASM OF SUBLINGUAL GLAND
142.8 MALIGNANT NEOPLASM OF OTHER MAJOR SALIVARY GLANDS
142.9 MALIGNANT NEOPLASM OF SALIVARY GLAND UNSPECIFIED
143.0 MALIGNANT NEOPLASM OF UPPER GUM
143.1 MALIGNANT NEOPLASM OF LOWER GUM
143.8 MALIGNANT NEOPLASM OF OTHER SITES OF GUM
143.9 MALIGNANT NEOPLASM OF GUM UNSPECIFIED
144.0 MALIGNANT NEOPLASM OF ANTERIOR PORTION OF FLOOR OF MOUTH
144.1 MALIGNANT NEOPLASM OF LATERAL PORTION OF FLOOR OF MOUTH
144.8 MALIGNANT NEOPLASM OF OTHER SITES OF FLOOR OF MOUTH
144.9 MALIGNANT NEOPLASM OF FLOOR OF MOUTH PART UNSPECIFIED
145.0 MALIGNANT NEOPLASM OF CHEEK MUCOSA
145.1 MALIGNANT NEOPLASM OF VESTIBULE OF MOUTH
145.2 MALIGNANT NEOPLASM OF HARD PALATE
145.3 MALIGNANT NEOPLASM OF SOFT PALATE
145.4 MALIGNANT NEOPLASM OF UVULA
145.5 MALIGNANT NEOPLASM OF PALATE UNSPECIFIED
145.6 MALIGNANT NEOPLASM OF RETROMOLAR AREA
145.8 MALIGNANT NEOPLASM OF OTHER SPECIFIED PARTS OF MOUTH
145.9 MALIGNANT NEOPLASM OF MOUTH UNSPECIFIED
146.0 MALIGNANT NEOPLASM OF TONSIL
146.1 MALIGNANT NEOPLASM OF TONSILLAR FOSSA
146.2 MALIGNANT NEOPLASM OF TONSILLAR PILLARS (ANTERIOR) (POSTERIOR)
146.3 MALIGNANT NEOPLASM OF VALLECULA EPIGLOTTICA
146.4 MALIGNANT NEOPLASM OF ANTERIOR ASPECT OF EPIGLOTTIS
146.5 MALIGNANT NEOPLASM OF JUNCTIONAL REGION OF OROPHARYNX
146.6 MALIGNANT NEOPLASM OF LATERAL WALL OF OROPHARYNX
146.7 MALIGNANT NEOPLASM OF POSTERIOR WALL OF OROPHARYNX
146.8 MALIGNANT NEOPLASM OF OTHER SPECIFIED SITES OF OROPHARYNX
146.9 MALIGNANT NEOPLASM OF OROPHARYNX UNSPECIFIED SITE
147.0 MALIGNANT NEOPLASM OF SUPERIOR WALL OF NASOPHARYNX
147.1 MALIGNANT NEOPLASM OF POSTERIOR WALL OF NASOPHARYNX
147.2 MALIGNANT NEOPLASM OF LATERAL WALL OF NASOPHARYNX
147.3 MALIGNANT NEOPLASM OF ANTERIOR WALL OF NASOPHARYNX
147.8 MALIGNANT NEOPLASM OF OTHER SPECIFIED SITES OF NASOPHARYNX
147.9 MALIGNANT NEOPLASM OF NASOPHARYNX UNSPECIFIED SITE
148.0 MALIGNANT NEOPLASM OF POSTCRICOID REGION OF HYPOPHARYNX
148.1 MALIGNANT NEOPLASM OF PYRIFORM SINUS
148.2 MALIGNANT NEOPLASM OF ARYEPIGLOTTIC FOLD HYPOPHARYNGEAL ASPECT
148.3 MALIGNANT NEOPLASM OF POSTERIOR HYPOPHARYNGEAL WALL
148.8 MALIGNANT NEOPLASM OF OTHER SPECIFIED SITES OF HYPOPHARYNX
148.9 MALIGNANT NEOPLASM OF HYPOPHARYNX UNSPECIFIED SITE
149.0 MALIGNANT NEOPLASM OF PHARYNX UNSPECIFIED
149.1 MALIGNANT NEOPLASM OF WALDEYER'S RING
149.8 MALIGNANT NEOPLASM OF OTHER SITES WITHIN THE LIP AND ORAL CAVITY
149.9 MALIGNANT NEOPLASM OF ILL-DEFINED SITES WITHIN THE LIP AND ORAL CAVITY
150.0 MALIGNANT NEOPLASM OF CERVICAL ESOPHAGUS
150.1 MALIGNANT NEOPLASM OF THORACIC ESOPHAGUS
150.2 MALIGNANT NEOPLASM OF ABDOMINAL ESOPHAGUS
150.3 MALIGNANT NEOPLASM OF UPPER THIRD OF ESOPHAGUS
150.4 MALIGNANT NEOPLASM OF MIDDLE THIRD OF ESOPHAGUS
150.5 MALIGNANT NEOPLASM OF LOWER THIRD OF ESOPHAGUS
150.8 MALIGNANT NEOPLASM OF OTHER SPECIFIED PART OF ESOPHAGUS
150.9 MALIGNANT NEOPLASM OF ESOPHAGUS UNSPECIFIED SITE
153.0 MALIGNANT NEOPLASM OF HEPATIC FLEXURE
153.1 MALIGNANT NEOPLASM OF TRANSVERSE COLON
153.2 MALIGNANT NEOPLASM OF DESCENDING COLON
153.3 MALIGNANT NEOPLASM OF SIGMOID COLON
153.4 MALIGNANT NEOPLASM OF CECUM
153.5 MALIGNANT NEOPLASM OF APPENDIX VERMIFORMIS
153.6 MALIGNANT NEOPLASM OF ASCENDING COLON
153.7 MALIGNANT NEOPLASM OF SPLENIC FLEXURE
153.8 MALIGNANT NEOPLASM OF OTHER SPECIFIED SITES OF LARGE INTESTINE
153.9 MALIGNANT NEOPLASM OF COLON UNSPECIFIED SITE
154.0 MALIGNANT NEOPLASM OF RECTOSIGMOID JUNCTION
154.1 MALIGNANT NEOPLASM OF RECTUM
154.2 MALIGNANT NEOPLASM OF ANAL CANAL
154.3 MALIGNANT NEOPLASM OF ANUS UNSPECIFIED SITE
154.8 MALIGNANT NEOPLASM OF OTHER SITES OF RECTUM RECTOSIGMOID JUNCTION AND ANUS
157.4 MALIGNANT NEOPLASM OF ISLETS OF LANGERHANS
158.8 MALIGNANT NEOPLASM OF SPECIFIED PARTS OF PERITONEUM
158.9 MALIGNANT NEOPLASM OF PERITONEUM UNSPECIFIED
161.0 MALIGNANT NEOPLASM OF GLOTTIS
161.1 MALIGNANT NEOPLASM OF SUPRAGLOTTIS
161.2 MALIGNANT NEOPLASM OF SUBGLOTTIS
161.3 MALIGNANT NEOPLASM OF LARYNGEAL CARTILAGES
161.8 MALIGNANT NEOPLASM OF OTHER SPECIFIED SITES OF LARYNX
161.9 MALIGNANT NEOPLASM OF LARYNX UNSPECIFIED
170.0 MALIGNANT NEOPLASM OF BONES OF SKULL AND FACE EXCEPT MANDIBLE
170.1 MALIGNANT NEOPLASM OF MANDIBLE
170.2 MALIGNANT NEOPLASM OF VERTEBRAL COLUMN EXCLUDING SACRUM AND COCCYX
170.3 MALIGNANT NEOPLASM OF RIBS STERNUM AND CLAVICLE
170.4 MALIGNANT NEOPLASM OF SCAPULA AND LONG BONES OF UPPER LIMB
170.5 MALIGNANT NEOPLASM OF SHORT BONES OF UPPER LIMB
170.6 MALIGNANT NEOPLASM OF PELVIC BONES SACRUM AND COCCYX
170.7 MALIGNANT NEOPLASM OF LONG BONES OF LOWER LIMB
170.8 MALIGNANT NEOPLASM OF SHORT BONES OF LOWER LIMB
170.9 MALIGNANT NEOPLASM OF BONE AND ARTICULAR CARTILAGE SITE UNSPECIFIED
172.0 MALIGNANT MELANOMA OF SKIN OF LIP
172.1 MALIGNANT MELANOMA OF SKIN OF EYELID INCLUDING CANTHUS
172.2 MALIGNANT MELANOMA OF SKIN OF EAR AND EXTERNAL AUDITORY CANAL
172.3 MALIGNANT MELANOMA OF SKIN OF OTHER AND UNSPECIFIED PARTS OF FACE
172.4 MALIGNANT MELANOMA OF SKIN OF SCALP AND NECK
172.5 MALIGNANT MELANOMA OF SKIN OF TRUNK EXCEPT SCROTUM
172.6 MALIGNANT MELANOMA OF SKIN OF UPPER LIMB INCLUDING SHOULDER
172.7 MALIGNANT MELANOMA OF SKIN OF LOWER LIMB INCLUDING HIP
172.8 MALIGNANT MELANOMA OF OTHER SPECIFIED SITES OF SKIN
172.9 MELANOMA OF SKIN SITE UNSPECIFIED
173.00 UNSPECIFIED MALIGNANT NEOPLASM OF SKIN OF LIP
173.01 BASAL CELL CARCINOMA OF SKIN OF LIP
173.02 SQUAMOUS CELL CARCINOMA OF SKIN OF LIP
173.09 OTHER SPECIFIED MALIGNANT NEOPLASM OF SKIN OF LIP
173.10 UNSPECIFIED MALIGNANT NEOPLASM OF EYELID, INCLUDING CANTHUS
173.11 BASAL CELL CARCINOMA OF EYELID, INCLUDING CANTHUS
173.12 SQUAMOUS CELL CARCINOMA OF EYELID, INCLUDING CANTHUS
173.19 OTHER SPECIFIED MALIGNANT NEOPLASM OF EYELID, INCLUDING CANTHUS
173.20 UNSPECIFIED MALIGNANT NEOPLASM OF SKIN OF EAR AND EXTERNAL AUDITORY CANAL
173.21 BASAL CELL CARCINOMA OF SKIN OF EAR AND EXTERNAL AUDITORY CANAL
173.22 SQUAMOUS CELL CARCINOMA OF SKIN OF EAR AND EXTERNAL AUDITORY CANAL
173.29 OTHER SPECIFIED MALIGNANT NEOPLASM OF SKIN OF EAR AND EXTERNAL AUDITORY CANAL
173.30 UNSPECIFIED MALIGNANT NEOPLASM OF SKIN OF OTHER AND UNSPECIFIED PARTS OF FACE
173.31 BASAL CELL CARCINOMA OF SKIN OF OTHER AND UNSPECIFIED PARTS OF FACE
173.32 SQUAMOUS CELL CARCINOMA OF SKIN OF OTHER AND UNSPECIFIED PARTS OF FACE
173.39 OTHER SPECIFIED MALIGNANT NEOPLASM OF SKIN OF OTHER AND UNSPECIFIED PARTS OF FACE
173.40 UNSPECIFIED MALIGNANT NEOPLASM OF SCALP AND SKIN OF NECK
173.41 BASAL CELL CARCINOMA OF SCALP AND SKIN OF NECK
173.42 SQUAMOUS CELL CARCINOMA OF SCALP AND SKIN OF NECK
173.49 OTHER SPECIFIED MALIGNANT NEOPLASM OF SCALP AND SKIN OF NECK
173.50 UNSPECIFIED MALIGNANT NEOPLASM OF SKIN OF TRUNK, EXCEPT SCROTUM
173.51 BASAL CELL CARCINOMA OF SKIN OF TRUNK, EXCEPT SCROTUM
173.52 SQUAMOUS CELL CARCINOMA OF SKIN OF TRUNK, EXCEPT SCROTUM
173.59 OTHER SPECIFIED MALIGNANT NEOPLASM OF SKIN OF TRUNK, EXCEPT SCROTUM
173.60 UNSPECIFIED MALIGNANT NEOPLASM OF SKIN OF UPPER LIMB, INCLUDING SHOULDER
173.61 BASAL CELL CARCINOMA OF SKIN OF UPPER LIMB, INCLUDING SHOULDER
173.62 SQUAMOUS CELL CARCINOMA OF SKIN OF UPPER LIMB, INCLUDING SHOULDER
173.69 OTHER SPECIFIED MALIGNANT NEOPLASM OF SKIN OF UPPER LIMB, INCLUDING SHOULDER
173.70 UNSPECIFIED MALIGNANT NEOPLASM OF SKIN OF LOWER LIMB, INCLUDING HIP
173.71 BASAL CELL CARCINOMA OF SKIN OF LOWER LIMB, INCLUDING HIP
173.72 SQUAMOUS CELL CARCINOMA OF SKIN OF LOWER LIMB, INCLUDING HIP
173.79 OTHER SPECIFIED MALIGNANT NEOPLASM OF SKIN OF LOWER LIMB, INCLUDING HIP
173.80 UNSPECIFIED MALIGNANT NEOPLASM OF OTHER SPECIFIED SITES OF SKIN
173.81 BASAL CELL CARCINOMA OF OTHER SPECIFIED SITES OF SKIN
173.82 SQUAMOUS CELL CARCINOMA OF OTHER SPECIFIED SITES OF SKIN
173.89 OTHER SPECIFIED MALIGNANT NEOPLASM OF OTHER SPECIFIED SITES OF SKIN
173.90 UNSPECIFIED MALIGNANT NEOPLASM OF SKIN, SITE UNSPECIFIED
173.91 BASAL CELL CARCINOMA OF SKIN, SITE UNSPECIFIED
173.92 SQUAMOUS CELL CARCINOMA OF SKIN, SITE UNSPECIFIED
173.99 OTHER SPECIFIED MALIGNANT NEOPLASM OF SKIN, SITE UNSPECIFIED
176.0 KAPOSI'S SARCOMA SKIN
176.1 KAPOSI'S SARCOMA SOFT TISSUE
176.2 KAPOSI'S SARCOMA PALATE
176.3 KAPOSI'S SARCOMA GASTROINTESTINAL SITES
176.4 KAPOSI'S SARCOMA LUNG
176.5 KAPOSI'S SARCOMA LYMPH NODES
176.8 KAPOSI'S SARCOMA OTHER SPECIFIED SITES
176.9 KAPOSI'S SARCOMA UNSPECIFIED SITE
183.0 MALIGNANT NEOPLASM OF OVARY
183.2 MALIGNANT NEOPLASM OF FALLOPIAN TUBE
183.3 MALIGNANT NEOPLASM OF BROAD LIGAMENT OF UTERUS
183.4 MALIGNANT NEOPLASM OF PARAMETRIUM
183.5 MALIGNANT NEOPLASM OF ROUND LIGAMENT OF UTERUS
183.8 MALIGNANT NEOPLASM OF OTHER SPECIFIED SITES OF UTERINE ADNEXA
183.9 MALIGNANT NEOPLASM OF UTERINE ADNEXA UNSPECIFIED SITE
184.4 MALIGNANT NEOPLASM OF VULVA UNSPECIFIED SITE
188.0 MALIGNANT NEOPLASM OF TRIGONE OF URINARY BLADDER
188.1 MALIGNANT NEOPLASM OF DOME OF URINARY BLADDER
188.2 MALIGNANT NEOPLASM OF LATERAL WALL OF URINARY BLADDER
188.3 MALIGNANT NEOPLASM OF ANTERIOR WALL OF URINARY BLADDER
188.4 MALIGNANT NEOPLASM OF POSTERIOR WALL OF URINARY BLADDER
188.5 MALIGNANT NEOPLASM OF BLADDER NECK
188.6 MALIGNANT NEOPLASM OF URETERIC ORIFICE
188.7 MALIGNANT NEOPLASM OF URACHUS
188.8 MALIGNANT NEOPLASM OF OTHER SPECIFIED SITES OF BLADDER
188.9 MALIGNANT NEOPLASM OF BLADDER PART UNSPECIFIED
189.0 MALIGNANT NEOPLASM OF KIDNEY EXCEPT PELVIS
189.1 MALIGNANT NEOPLASM OF RENAL PELVIS
191.0 MALIGNANT NEOPLASM OF CEREBRUM EXCEPT LOBES AND VENTRICLES
191.1 MALIGNANT NEOPLASM OF FRONTAL LOBE
191.2 MALIGNANT NEOPLASM OF TEMPORAL LOBE
191.3 MALIGNANT NEOPLASM OF PARIETAL LOBE
191.4 MALIGNANT NEOPLASM OF OCCIPITAL LOBE
191.5 MALIGNANT NEOPLASM OF VENTRICLES
191.6 MALIGNANT NEOPLASM OF CEREBELLUM NOS
191.7 MALIGNANT NEOPLASM OF BRAIN STEM
191.8 MALIGNANT NEOPLASM OF OTHER PARTS OF BRAIN
191.9 MALIGNANT NEOPLASM OF BRAIN UNSPECIFIED SITE
200.00 RETICULOSARCOMA UNSPECIFIED SITE
200.01 RETICULOSARCOMA INVOLVING LYMPH NODES OF HEAD FACE AND NECK
200.02 RETICULOSARCOMA INVOLVING INTRATHORACIC LYMPH NODES
200.03 RETICULOSARCOMA INVOLVING INTRA-ABDOMINAL LYMPH NODES
200.04 RETICULOSARCOMA INVOLVING LYMPH NODES OF AXILLA AND UPPER LIMB
200.05 RETICULOSARCOMA INVOLVING LYMPH NODES OF INGUINAL REGION AND LOWER LIMB
200.06 RETICULOSARCOMA INVOLVING INTRAPELVIC LYMPH NODES
200.07 RETICULOSARCOMA INVOLVING SPLEEN
200.08 RETICULOSARCOMA INVOLVING LYMPH NODES OF MULTIPLE SITES
200.10 LYMPHOSARCOMA UNSPECIFIED SITE
200.11 LYMPHOSARCOMA INVOLVING LYMPH NODES OF HEAD FACE AND NECK
200.12 LYMPHOSARCOMA INVOLVING INTRATHORACIC LYMPH NODES
200.13 LYMPHOSARCOMA INVOLVING INTRA-ABDOMINAL LYMPH NODES
200.14 LYMPHOSARCOMA INVOLVING LYMPH NODES OF AXILLA AND UPPER LIMB
200.15 LYMPHOSARCOMA INVOLVING LYMPH NODES OF INGUINAL REGION AND LOWER LIMB
200.16 LYMPHOSARCOMA INVOLVING INTRAPELVIC LYMPH NODES
200.17 LYMPHOSARCOMA INVOLVING SPLEEN
200.18 LYMPHOSARCOMA INVOLVING LYMPH NODES OF MULTIPLE SITES
200.20 BURKITT'S TUMOR OR LYMPHOMA UNSPECIFIED SITE
200.21 BURKITT'S TUMOR OR LYMPHOMA INVOLVING LYMPH NODES OF HEAD FACE AND NECK
200.22 BURKITT'S TUMOR OR LYMPHOMA INVOLVING INTRATHORACIC LYMPH NODES
200.23 BURKITT'S TUMOR OR LYMPHOMA INVOLVING INTRA-ABDOMINAL LYMPH NODES
200.24 BURKITT'S TUMOR OR LYMPHOMA INVOLVING LYMPH NODES OF AXILLA AND UPPER LIMB
200.25 BURKITT'S TUMOR OR LYMPHOMA INVOLVING LYMPH NODES OF INGUINAL REGION AND LOWER LIMB
200.26 BURKITT'S TUMOR OR LYMPHOMA INVOLVING INTRAPELVIC LYMPH NODES
200.27 BURKITT'S TUMOR OR LYMPHOMA INVOLVING SPLEEN
200.28 BURKITT'S TUMOR OR LYMPHOMA INVOLVING LYMPH NODES OF MULTIPLE SITES
200.30 MARGINAL ZONE LYMPHOMA, UNSPECIFIED SITE, EXTRANODAL AND SOLID ORGAN SITES
200.31 MARGINAL ZONE LYMPHOMA,LYMPH NODES OF HEAD, FACE, AND NECK
200.32 MARGINAL ZONE LYMPHOMA,INTRATHORACIC LYMPH NODES
200.33 MARGINAL ZONE LYMPHOMA, INTRAABDOMINAL LYMPH NODES
200.34 MARGINAL ZONE LYMPHOMA, LYMPH NODES OF AXILLA AND UPPER LIMB
200.35 MARGINAL ZONE LYMPHOMA, LYMPH NODES OF INGUINAL REGION AND LOWER LIMB
200.36 MARGINAL ZONE LYMPHOMA, INTRAPELVIC LYMPH NODES
200.37 MARGINAL ZONE LYMPHOMA, SPLEEN
200.38 MARGINAL ZONE LYMPHOMA, LYMPH NODES OF MULTIPLE SITES
200.40 MANTLE CELL LYMPHOMA, UNSPECIFIED SITE, EXTRANODAL AND SOLID ORGAN SITES
200.41 MANTLE CELL LYMPHOMA, LYMPH NODES OF HEAD, FACE, AND NECK
200.42 MANTLE CELL LYMPHOMA, INTRATHORACIC LYMPH NODES
200.43 MANTLE CELL LYMPHOMA, INTRA-ABDOMINAL LYMPH NODES
200.44 MANTLE CELL LYMPHOMA, LYMPH NODES OF AXILLA AND UPPER LIMB
200.45 MANTLE CELL LYMPHOMA, LYMPH NODES OF INGUINAL REGION AND LOWER LIMB
200.46 MANTLE CELL LYMPHOMA, INTRAPELVIC LYMPH NODES
200.47 MANTLE CELL LYMPHOMA, SPLEEN
200.48 MANTLE CELL LYMPHOMA, LYMPH NODES OF MULTIPLE SITES
200.50 PRIMARY CENTRAL NERVOUS SYSTEM LYMPHOMA, UNSPECIFIED SITE, EXTRANODAL AND SOLID ORGAN SITES
200.51 PRIMARY CENTRAL NERVOUS SYSTEM LYMPHOMA, LYMPH NODES OF HEAD, FACE, AND NECK
200.52 PRIMARY CENTRAL NERVOUS SYSTEM LYMPHOMA, INTRATHORACIC LYMPH NODES
200.53 PRIMARY CENTRAL NERVOUS SYSTEM LYMPHOMA, INTRA-ABDOMINAL LYMPH NODES
200.54 PRIMARY CENTRAL NERVOUS SYSTEM LYMPHOMA, LYMPH NODES OF AXILLA AND UPPER LIMB
200.55 PRIMARY CENTRAL NERVOUS SYSTEM LYMPHOMA, LYMPH NODES OF INGUINAL REGION AND LOWER LIMB
200.56 PRIMARY CENTRAL NERVOUS SYSTEM LYMPHOMA, INTRAPELVIC LYMPH NODES
200.57 PRIMARY CENTRAL NERVOUS SYSTEM LYMPHOMA, SPLEEN
200.58 PRIMARY CENTRAL NERVOUS SYSTEM LYMPHOMA, LYMPH NODES OF MULTIPLE SITES
200.60 ANAPLASTIC LARGE CELL LYMPHOMA, UNSPECIFIED SITE, EXTRANODAL AND SOLID ORGAN SITES
200.61 ANAPLASTIC LARGE CELL LYMPHOMA, LYMPH NODES OF HEAD, FACE, AND NECK
200.62 ANAPLASTIC LARGE CELL LYMPHOMA, INTRATHORACIC LYMPH NODES
200.63 ANAPLASTIC LARGE CELL LYMPHOMA, INTRA-ABDOMINAL LYMPH NODES
200.64 ANAPLASTIC LARGE CELL LYMPHOMA, LYMPH NODES OF AXILLA AND UPPER LIMB
200.65 ANAPLASTIC LARGE CELL LYMPHOMA, LYMPH NODES OF INGUINAL REGION AND LOWER LIMB
200.66 ANAPLASTIC LARGE CELL LYMPHOMA, INTRAPELVIC LYMPH NODES
200.67 ANAPLASTIC LARGE CELL LYMPHOMA, SPLEEN
200.68 ANAPLASTIC LARGE CELL LYMPHOMA, LYMPH NODES OF MULTIPLE SITES
200.70 LARGE CELL LYMPHOMA, UNSPECIFIED SITE, EXTRANODAL AND SOLID ORGAN SITES
200.71 LARGE CELL LYMPHOMA, LYMPH NODES OF HEAD, FACE, AND NECK
200.72 LARGE CELL LYMPHOMA, INTRATHORACIC LYMPH NODES
200.73 LARGE CELL LYMPHOMA, INTRA-ABDOMINAL LYMPH NODES
200.74 LARGE CELL LYMPHOMA, LYMPH NODES OF AXILLA AND UPPER LIMB
200.75 LARGE CELL LYMPHOMA, LYMPH NODES OF INGUINAL REGION AND LOWER LIMB
200.76 LARGE CELL LYMPHOMA, INTRAPELVIC LYMPH NODES
200.77 LARGE CELL LYMPHOMA, SPLEEN
200.78 LARGE CELL LYMPHOMA, LYMPH NODES OF MULTIPLE SITES
200.80 OTHER NAMED VARIANTS OF LYMPHOSARCOMA AND RETICULOSARCOMA UNSPECIFIED SITE
200.81 OTHER NAMED VARIANTS OF LYMPHOSARCOMA AND RETICULOSARCOMA INVOLVING LYMPH NODES OF HEAD FACE AND NECK
200.82 OTHER NAMED VARIANTS OF LYMPHOSARCOMA AND RETICULOSARCOMA INVOLVING INTRATHORACIC LYMPH NODES
200.83 OTHER NAMED VARIANTS OF LYMPHOSARCOMA AND RETICULOSARCOMA INVOLVING INTRA-ABDOMINAL LYMPH NODES
200.84 OTHER NAMED VARIANTS OF LYMPHOSARCOMA AND RETICULOSARCOMA INVOLVING LYMPH NODES OF AXILLA AND UPPER LIMB
200.85 OTHER NAMED VARIANTS OF LYMPHOSARCOMA AND RETICULOSARCOMA INVOLVING LYMPH NODES OF INGUINAL REGION AND LOWER LIMB
200.86 OTHER NAMED VARIANTS OF LYMPHOSARCOMA AND RETICULOSARCOMA INVOLVING INTRAPELVIC LYMPH NODES
200.87 OTHER NAMED VARIANTS OF LYMPHOSARCOMA AND RETICULOSARCOMA INVOLVING SPLEEN
200.88 OTHER NAMED VARIANTS OF LYMPHOSARCOMA AND RETICULOSARCOMA INVOLVING LYMPH NODES OF MULTIPLE SITES
202.00 NODULAR LYMPHOMA UNSPECIFIED SITE
202.01 NODULAR LYMPHOMA INVOLVING LYMPH NODES OF HEAD FACE AND NECK
202.02 NODULAR LYMPHOMA INVOLVING INTRATHORACIC LYMPH NODES
202.03 NODULAR LYMPHOMA INVOLVING INTRA-ABDOMINAL LYMPH NODES
202.04 NODULAR LYMPHOMA INVOLVING LYMPH NODES OF AXILLA AND UPPER LIMB
202.05 NODULAR LYMPHOMA INVOLVING LYMPH NODES OF INGUINAL REGION AND LOWER LIMB
202.06 NODULAR LYMPHOMA INVOLVING INTRAPELVIC LYMPH NODES
202.07 NODULAR LYMPHOMA INVOLVING SPLEEN
202.08 NODULAR LYMPHOMA INVOLVING LYMPH NODES OF MULTIPLE SITES
202.10 MYCOSIS FUNGOIDES UNSPECIFIED SITE
202.11 MYCOSIS FUNGOIDES INVOLVING LYMPH NODES OF HEAD FACE AND NECK
202.12 MYCOSIS FUNGOIDES INVOLVING INTRATHORACIC LYMPH NODES
202.13 MYCOSIS FUNGOIDES INVOLVING INTRA-ABDOMINAL LYMPH NODES
202.14 MYCOSIS FUNGOIDES INVOLVING LYMPH NODES OF AXILLA AND UPPER LIMB
202.15 MYCOSIS FUNGOIDES INVOLVING LYMPH NODES OF INGUINAL REGION AND LOWER LIMB
202.16 MYCOSIS FUNGOIDES INVOLVING INTRAPELVIC LYMPH NODES
202.17 MYCOSIS FUNGOIDES INVOLVING SPLEEN
202.18 MYCOSIS FUNGOIDES INVOLVING LYMPH NODES OF MULTIPLE SITES
202.20 SEZARY'S DISEASE UNSPECIFIED SITE
202.21 SEZARY'S DISEASE INVOLVING LYMPH NODES OF HEAD FACE AND NECK
202.22 SEZARY'S DISEASE INVOLVING INTRATHORACIC LYMPH NODES
202.23 SEZARY'S DISEASE INVOLVING INTRA-ABDOMINAL LYMPH NODES
202.24 SEZARY'S DISEASE INVOLVING LYMPH NODES OF AXILLA AND UPPER LIMB
202.25 SEZARY'S DISEASE INVOLVING LYMPH NODES OF INGUINAL REGION AND LOWER LIMB
202.26 SEZARY'S DISEASE INVOLVING INTRAPELVIC LYMPH NODES
202.27 SEZARY'S DISEASE INVOLVING SPLEEN
202.28 SEZARY'S DISEASE INVOLVING LYMPH NODES OF MULTIPLE SITES
202.30 MALIGNANT HISTIOCYTOSIS UNSPECIFIED SITE
202.31 MALIGNANT HISTIOCYTOSIS INVOLVING LYMPH NODES OF HEAD FACE AND NECK
202.32 MALIGNANT HISTIOCYTOSIS INVOLVING INTRATHORACIC LYMPH NODES
202.33 MALIGNANT HISTIOCYTOSIS INVOLVING INTRA-ABDOMINAL LYMPH NODES
202.34 MALIGNANT HISTIOCYTOSIS INVOLVING LYMPH NODES OF AXILLA AND UPPER LIMB
202.35 MALIGNANT HISTIOCYTOSIS INVOLVING LYMPH NODES OF INGUINAL REGION AND LOWER LIMB
202.36 MALIGNANT HISTIOCYTOSIS INVOLVING INTRAPELVIC LYMPH NODES
202.37 MALIGNANT HISTIOCYTOSIS INVOLVING SPLEEN
202.38 MALIGNANT HISTIOCYTOSIS INVOLVING LYMPH NODES OF MULTIPLE SITES
202.40 LEUKEMIC RETICULOENDOTHELIOSIS UNSPECIFIED SITE
202.41 LEUKEMIC RETICULOENDOTHELIOSIS INVOLVING LYMPH NODES OF HEAD FACE AND NECK
202.42 LEUKEMIC RETICULOENDOTHELIOSIS INVOLVING INTRATHORACIC LYMPH NODES
202.43 LEUKEMIC RETICULOENDOTHELIOSIS INVOLVING INTRA-ABDOMINAL LYMPH NODES
202.44 LEUKEMIC RETICULOENDOTHELIOSIS INVOLVING LYMPH NODES OF AXILLA AND UPPER ARM
202.45 LEUKEMIC RETICULOENDOTHELIOSIS INVOLVING LYMPH NODES OF INGUINAL REGION AND LOWER LIMB
202.46 LEUKEMIC RETICULOENDOTHELIOSIS INVOLVING INTRAPELVIC LYMPH NODES
202.47 LEUKEMIC RETICULOENDOTHELIOSIS INVOLVING SPLEEN
202.48 LEUKEMIC RETICULOENDOTHELIOSIS INVOLVING LYMPH NODES OF MULTIPLE SITES
202.50 LETTERER-SIWE DISEASE UNSPECIFIED SITE
202.51 LETTERER-SIWE DISEASE INVOLVING LYMPH NODES OF HEAD FACE AND NECK
202.52 LETTERER-SIWE DISEASE INVOLVING INTRATHORACIC LYMPH NODES
202.53 LETTERER-SIWE DISEASE INVOLVING INTRA-ABDOMINAL LYMPH NODES
202.54 LETTERER-SIWE DISEASE INVOLVING LYMPH NODES OF AXILLA AND UPPER LIMB
202.55 LETTERER-SIWE DISEASE INVOLVING LYMPH NODES OF INGUINAL REGION AND LOWER LIMB
202.56 LETTERER-SIWE DISEASE INVOLVING INTRAPELVIC LYMPH NODES
202.57 LETTERER-SIWE DISEASE INVOLVING SPLEEN
202.58 LETTERER-SIWE DISEASE INVOLVING LYMPH NODES OF MULTIPLE SITES
202.60 MALIGNANT MAST CELL TUMORS UNSPECIFIED SITE
202.61 MALIGNANT MAST CELL TUMORS INVOLVING LYMPH NODES OF HEAD FACE AND NECK
202.62 MALIGNANT MAST CELL TUMORS INVOLVING INTRATHORACIC LYMPH NODES
202.63 MALIGNANT MAST CELL TUMORS INVOLVING INTRA-ABDOMINAL LYMPH NODES
202.64 MALIGNANT MAST CELL TUMORS INVOLVING LYMPH NODES OF AXILLA AND UPPER LIMB
202.65 MALIGNANT MAST CELL TUMORS INVOLVING LYMPH NODES OF INGUINAL REGION AND LOWER LIMB
202.66 MALIGNANT MAST CELL TUMORS INVOLVING INTRAPELVIC LYMPH NODES
202.67 MALIGNANT MAST CELL TUMORS INVOLVING SPLEEN
202.68 MALIGNANT MAST CELL TUMORS INVOLVING LYMPH NODES OF MULTIPLE SITES
202.70 PERIPHERAL T CELL LYMPHOMA, UNSPECIFIED SITE, EXTRANODAL AND SOLID ORGAN SITES
202.71 PERIPHERAL T CELL LYMPHOMA, LYMPH NODES OF HEAD, FACE, AND NECK
202.72 PERIPHERAL T CELL LYMPHOMA, INTRATHORACIC LYMPH NODES
202.73 PERIPHERAL T CELL LYMPHOMA, INTRA-ABDOMINAL LYMPH NODES
202.74 PERIPHERAL T CELL LYMPHOMA, LYMPH NODES OF AXILLA AND UPPER LIMB
202.75 PERIPHERAL T CELL LYMPHOMA, LYMPH NODES OF INGUINAL REGION AND LOWER LIMB
202.76 PERIPHERAL T CELL LYMPHOMA, INTRAPELVIC LYMPH NODES
202.77 PERIPHERAL T CELL LYMPHOMA, SPLEEN
202.78 PERIPHERAL T CELL LYMPHOMA, LYMPH NODES OF MULTIPLE SITES
202.80 OTHER MALIGNANT LYMPHOMAS UNSPECIFIED SITE
202.81 OTHER MALIGNANT LYMPHOMAS INVOLVING LYMPH NODES OF HEAD FACE AND NECK
202.82 OTHER MALIGNANT LYMPHOMAS INVOLVING INTRATHORACIC LYMPH NODES
202.83 OTHER MALIGNANT LYMPHOMAS INVOLVING INTRA-ABDOMINAL LYMPH NODES
202.84 OTHER MALIGNANT LYMPHOMAS INVOLVING LYMPH NODES OF AXILLA AND UPPER LIMB
202.85 OTHER MALIGNANT LYMPHOMAS INVOLVING LYMPH NODES OF INGUINAL REGION AND LOWER LIMB
202.86 OTHER MALIGNANT LYMPHOMAS INVOLVING INTRAPELVIC LYMPH NODES
202.87 OTHER MALIGNANT LYMPHOMAS INVOLVING SPLEEN
202.88 OTHER MALIGNANT LYMPHOMAS INVOLVING LYMPH NODES OF MULTIPLE SITES
202.90 OTHER AND UNSPECIFIED MALIGNANT NEOPLASMS OF LYMPHOID AND HISTIOCYTIC TISSUE UNSPECIFIED SITE
202.91 OTHER AND UNSPECIFIED MALIGNANT NEOPLASMS OF LYMPHOID AND HISTIOCYTIC TISSUE INVOLVING LYMPH NODES OF HEAD FACE AND NECK
202.92 OTHER AND UNSPECIFIED MALIGNANT NEOPLASMS OF LYMPHOID AND HISTIOCYTIC TISSUE INVOLVING INTRATHORACIC LYMPH NODES
202.93 OTHER AND UNSPECIFIED MALIGNANT NEOPLASMS OF LYMPHOID AND HISTIOCYTIC TISSUE INVOLVING INTRA-ABDOMINAL LYMPH NODES
202.94 OTHER AND UNSPECIFIED MALIGNANT NEOPLASMS OF LYMPHOID AND HISTIOCYTIC TISSUE INVOLVING LYMPH NODES OF AXILLA AND UPPER LIMB
202.95 OTHER AND UNSPECIFIED MALIGNANT NEOPLASMS OF LYMPHOID AND HISTIOCYTIC TISSUE INVOLVING LYMPH NODES OF INGUINAL REGION AND LOWER LIMB
202.96 OTHER AND UNSPECIFIED MALIGNANT NEOPLASMS OF LYMPHOID AND HISTIOCYTIC TISSUE INVOLVING INTRAPELVIC LYMPH NODES
202.97 OTHER AND UNSPECIFIED MALIGNANT NEOPLASMS OF LYMPHOID AND HISTIOCYTIC TISSUE INVOLVING SPLEEN
202.98 OTHER AND UNSPECIFIED MALIGNANT NEOPLASMS OF LYMPHOID AND HISTIOCYTIC TISSUE INVOLVING LYMPH NODES OF MULTIPLE SITES
203.00 MULTIPLE MYELOMA, WITHOUT MENTION OF HAVING ACHIEVED REMISSION
203.01 MULTIPLE MYELOMA IN REMISSION
203.02 MULTIPLE MYELOMA, IN RELAPSE
203.10 PLASMA CELL LEUKEMIA, WITHOUT MENTION OF HAVING ACHIEVED REMISSION
203.11 PLASMA CELL LEUKEMIA IN REMISSION
203.12 PLASMA CELL LEUKEMIA, IN RELAPSE
203.80 OTHER IMMUNOPROLIFERATIVE NEOPLASMS, WITHOUT MENTION OF HAVING ACHIEVED REMISSION
203.81 OTHER IMMUNOPROLIFERATIVE NEOPLASMS IN REMISSION
203.82 OTHER IMMUNOPROLIFERATIVE NEOPLASMS, IN RELAPSE
204.10 CHRONIC LYMPHOID LEUKEMIA, WITHOUT MENTION OF HAVING ACHIEVED REMISSION
204.12 CHRONIC LYMPHOID LEUKEMIA, IN RELAPSE
205.10 CHRONIC MYELOID LEUKEMIA, WITHOUT MENTION OF HAVING ACHIEVED REMISSION
205.12 CHRONIC MYELOID LEUKEMIA, IN RELAPSE
238.4 POLYCYTHEMIA VERA
238.71 ESSENTIAL THROMBOCYTHEMIA
259.2 CARCINOID SYNDROME
289.9 UNSPECIFIED DISEASES OF BLOOD AND BLOOD-FORMING ORGANS
For J9215 (Interferon alfa-N3):
070.54 CHRONIC HEPATITIS C WITHOUT HEPATIC COMA
078.11 CONDYLOMA ACUMINATUM
158.8 MALIGNANT NEOPLASM OF SPECIFIED PARTS OF PERITONEUM
158.9 MALIGNANT NEOPLASM OF PERITONEUM UNSPECIFIED
161.0 MALIGNANT NEOPLASM OF GLOTTIS
161.1 MALIGNANT NEOPLASM OF SUPRAGLOTTIS
161.2 MALIGNANT NEOPLASM OF SUBGLOTTIS
161.3 MALIGNANT NEOPLASM OF LARYNGEAL CARTILAGES
161.8 MALIGNANT NEOPLASM OF OTHER SPECIFIED SITES OF LARYNX
161.9 MALIGNANT NEOPLASM OF LARYNX UNSPECIFIED
172.0 MALIGNANT MELANOMA OF SKIN OF LIP
172.1 MALIGNANT MELANOMA OF SKIN OF EYELID INCLUDING CANTHUS
172.2 MALIGNANT MELANOMA OF SKIN OF EAR AND EXTERNAL AUDITORY CANAL
172.3 MALIGNANT MELANOMA OF SKIN OF OTHER AND UNSPECIFIED PARTS OF FACE
172.4 MALIGNANT MELANOMA OF SKIN OF SCALP AND NECK
172.5 MALIGNANT MELANOMA OF SKIN OF TRUNK EXCEPT SCROTUM
172.6 MALIGNANT MELANOMA OF SKIN OF UPPER LIMB INCLUDING SHOULDER
172.7 MALIGNANT MELANOMA OF SKIN OF LOWER LIMB INCLUDING HIP
172.8 MALIGNANT MELANOMA OF OTHER SPECIFIED SITES OF SKIN
172.9 MELANOMA OF SKIN SITE UNSPECIFIED
176.0 KAPOSI'S SARCOMA SKIN
176.1 KAPOSI'S SARCOMA SOFT TISSUE
176.2 KAPOSI'S SARCOMA PALATE
176.3 KAPOSI'S SARCOMA GASTROINTESTINAL SITES
176.4 KAPOSI'S SARCOMA LUNG
176.5 KAPOSI'S SARCOMA LYMPH NODES
176.8 KAPOSI'S SARCOMA OTHER SPECIFIED SITES
176.9 KAPOSI'S SARCOMA UNSPECIFIED SITE
183.0 MALIGNANT NEOPLASM OF OVARY
183.2 MALIGNANT NEOPLASM OF FALLOPIAN TUBE
183.3 MALIGNANT NEOPLASM OF BROAD LIGAMENT OF UTERUS
183.4 MALIGNANT NEOPLASM OF PARAMETRIUM
183.5 MALIGNANT NEOPLASM OF ROUND LIGAMENT OF UTERUS
183.8 MALIGNANT NEOPLASM OF OTHER SPECIFIED SITES OF UTERINE ADNEXA
183.9 MALIGNANT NEOPLASM OF UTERINE ADNEXA UNSPECIFIED SITE
188.0 MALIGNANT NEOPLASM OF TRIGONE OF URINARY BLADDER
188.1 MALIGNANT NEOPLASM OF DOME OF URINARY BLADDER
188.2 MALIGNANT NEOPLASM OF LATERAL WALL OF URINARY BLADDER
188.3 MALIGNANT NEOPLASM OF ANTERIOR WALL OF URINARY BLADDER
188.4 MALIGNANT NEOPLASM OF POSTERIOR WALL OF URINARY BLADDER
188.5 MALIGNANT NEOPLASM OF BLADDER NECK
188.6 MALIGNANT NEOPLASM OF URETERIC ORIFICE
188.7 MALIGNANT NEOPLASM OF URACHUS
188.8 MALIGNANT NEOPLASM OF OTHER SPECIFIED SITES OF BLADDER
188.9 MALIGNANT NEOPLASM OF BLADDER PART UNSPECIFIED
189.0 MALIGNANT NEOPLASM OF KIDNEY EXCEPT PELVIS
189.1 MALIGNANT NEOPLASM OF RENAL PELVIS
200.00 RETICULOSARCOMA UNSPECIFIED SITE
200.01 RETICULOSARCOMA INVOLVING LYMPH NODES OF HEAD FACE AND NECK
200.02 RETICULOSARCOMA INVOLVING INTRATHORACIC LYMPH NODES
200.03 RETICULOSARCOMA INVOLVING INTRA-ABDOMINAL LYMPH NODES
200.04 RETICULOSARCOMA INVOLVING LYMPH NODES OF AXILLA AND UPPER LIMB
200.05 RETICULOSARCOMA INVOLVING LYMPH NODES OF INGUINAL REGION AND LOWER LIMB
200.06 RETICULOSARCOMA INVOLVING INTRAPELVIC LYMPH NODES
200.07 RETICULOSARCOMA INVOLVING SPLEEN
200.08 RETICULOSARCOMA INVOLVING LYMPH NODES OF MULTIPLE SITES
200.10 LYMPHOSARCOMA UNSPECIFIED SITE
200.11 LYMPHOSARCOMA INVOLVING LYMPH NODES OF HEAD FACE AND NECK
200.12 LYMPHOSARCOMA INVOLVING INTRATHORACIC LYMPH NODES
200.13 LYMPHOSARCOMA INVOLVING INTRA-ABDOMINAL LYMPH NODES
200.14 LYMPHOSARCOMA INVOLVING LYMPH NODES OF AXILLA AND UPPER LIMB
200.15 LYMPHOSARCOMA INVOLVING LYMPH NODES OF INGUINAL REGION AND LOWER LIMB
200.16 LYMPHOSARCOMA INVOLVING INTRAPELVIC LYMPH NODES
200.17 LYMPHOSARCOMA INVOLVING SPLEEN
200.18 LYMPHOSARCOMA INVOLVING LYMPH NODES OF MULTIPLE SITES
200.20 BURKITT'S TUMOR OR LYMPHOMA UNSPECIFIED SITE
200.21 BURKITT'S TUMOR OR LYMPHOMA INVOLVING LYMPH NODES OF HEAD FACE AND NECK
200.22 BURKITT'S TUMOR OR LYMPHOMA INVOLVING INTRATHORACIC LYMPH NODES
200.23 BURKITT'S TUMOR OR LYMPHOMA INVOLVING INTRA-ABDOMINAL LYMPH NODES
200.24 BURKITT'S TUMOR OR LYMPHOMA INVOLVING LYMPH NODES OF AXILLA AND UPPER LIMB
200.25 BURKITT'S TUMOR OR LYMPHOMA INVOLVING LYMPH NODES OF INGUINAL REGION AND LOWER LIMB
200.26 BURKITT'S TUMOR OR LYMPHOMA INVOLVING INTRAPELVIC LYMPH NODES
200.27 BURKITT'S TUMOR OR LYMPHOMA INVOLVING SPLEEN
200.28 BURKITT'S TUMOR OR LYMPHOMA INVOLVING LYMPH NODES OF MULTIPLE SITES
200.30 MARGINAL ZONE LYMPHOMA, UNSPECIFIED SITE, EXTRANODAL AND SOLID ORGAN SITES
200.31 MARGINAL ZONE LYMPHOMA,LYMPH NODES OF HEAD, FACE, AND NECK
200.32 MARGINAL ZONE LYMPHOMA,INTRATHORACIC LYMPH NODES
200.33 MARGINAL ZONE LYMPHOMA, INTRAABDOMINAL LYMPH NODES
200.34 MARGINAL ZONE LYMPHOMA, LYMPH NODES OF AXILLA AND UPPER LIMB
200.35 MARGINAL ZONE LYMPHOMA, LYMPH NODES OF INGUINAL REGION AND LOWER LIMB
200.36 MARGINAL ZONE LYMPHOMA, INTRAPELVIC LYMPH NODES
200.37 MARGINAL ZONE LYMPHOMA, SPLEEN
200.38 MARGINAL ZONE LYMPHOMA, LYMPH NODES OF MULTIPLE SITES
200.40 MANTLE CELL LYMPHOMA, UNSPECIFIED SITE, EXTRANODAL AND SOLID ORGAN SITES
200.41 MANTLE CELL LYMPHOMA, LYMPH NODES OF HEAD, FACE, AND NECK
200.42 MANTLE CELL LYMPHOMA, INTRATHORACIC LYMPH NODES
200.43 MANTLE CELL LYMPHOMA, INTRA-ABDOMINAL LYMPH NODES
200.44 MANTLE CELL LYMPHOMA, LYMPH NODES OF AXILLA AND UPPER LIMB
200.45 MANTLE CELL LYMPHOMA, LYMPH NODES OF INGUINAL REGION AND LOWER LIMB
200.46 MANTLE CELL LYMPHOMA, INTRAPELVIC LYMPH NODES
200.47 MANTLE CELL LYMPHOMA, SPLEEN
200.48 MANTLE CELL LYMPHOMA, LYMPH NODES OF MULTIPLE SITES
200.50 PRIMARY CENTRAL NERVOUS SYSTEM LYMPHOMA, UNSPECIFIED SITE, EXTRANODAL AND SOLID ORGAN SITES
200.51 PRIMARY CENTRAL NERVOUS SYSTEM LYMPHOMA, LYMPH NODES OF HEAD, FACE, AND NECK
200.52 PRIMARY CENTRAL NERVOUS SYSTEM LYMPHOMA, INTRATHORACIC LYMPH NODES
200.53 PRIMARY CENTRAL NERVOUS SYSTEM LYMPHOMA, INTRA-ABDOMINAL LYMPH NODES
200.54 PRIMARY CENTRAL NERVOUS SYSTEM LYMPHOMA, LYMPH NODES OF AXILLA AND UPPER LIMB
200.55 PRIMARY CENTRAL NERVOUS SYSTEM LYMPHOMA, LYMPH NODES OF INGUINAL REGION AND LOWER LIMB
200.56 PRIMARY CENTRAL NERVOUS SYSTEM LYMPHOMA, INTRAPELVIC LYMPH NODES
200.57 PRIMARY CENTRAL NERVOUS SYSTEM LYMPHOMA, SPLEEN
200.58 PRIMARY CENTRAL NERVOUS SYSTEM LYMPHOMA, LYMPH NODES OF MULTIPLE SITES
200.60 ANAPLASTIC LARGE CELL LYMPHOMA, UNSPECIFIED SITE, EXTRANODAL AND SOLID ORGAN SITES
200.61 ANAPLASTIC LARGE CELL LYMPHOMA, LYMPH NODES OF HEAD, FACE, AND NECK
200.62 ANAPLASTIC LARGE CELL LYMPHOMA, INTRATHORACIC LYMPH NODES
200.63 ANAPLASTIC LARGE CELL LYMPHOMA, INTRA-ABDOMINAL LYMPH NODES
200.64 ANAPLASTIC LARGE CELL LYMPHOMA, LYMPH NODES OF AXILLA AND UPPER LIMB
200.65 ANAPLASTIC LARGE CELL LYMPHOMA, LYMPH NODES OF INGUINAL REGION AND LOWER LIMB
200.66 ANAPLASTIC LARGE CELL LYMPHOMA, INTRAPELVIC LYMPH NODES
200.67 ANAPLASTIC LARGE CELL LYMPHOMA, SPLEEN
200.68 ANAPLASTIC LARGE CELL LYMPHOMA, LYMPH NODES OF MULTIPLE SITES
200.70 LARGE CELL LYMPHOMA, UNSPECIFIED SITE, EXTRANODAL AND SOLID ORGAN SITES
200.71 LARGE CELL LYMPHOMA, LYMPH NODES OF HEAD, FACE, AND NECK
200.72 LARGE CELL LYMPHOMA, INTRATHORACIC LYMPH NODES
200.73 LARGE CELL LYMPHOMA, INTRA-ABDOMINAL LYMPH NODES
200.74 LARGE CELL LYMPHOMA, LYMPH NODES OF AXILLA AND UPPER LIMB
200.75 LARGE CELL LYMPHOMA, LYMPH NODES OF INGUINAL REGION AND LOWER LIMB
200.76 LARGE CELL LYMPHOMA, INTRAPELVIC LYMPH NODES
200.77 LARGE CELL LYMPHOMA, SPLEEN
200.78 LARGE CELL LYMPHOMA, LYMPH NODES OF MULTIPLE SITES
200.80 OTHER NAMED VARIANTS OF LYMPHOSARCOMA AND RETICULOSARCOMA UNSPECIFIED SITE
200.81 OTHER NAMED VARIANTS OF LYMPHOSARCOMA AND RETICULOSARCOMA INVOLVING LYMPH NODES OF HEAD FACE AND NECK
200.82 OTHER NAMED VARIANTS OF LYMPHOSARCOMA AND RETICULOSARCOMA INVOLVING INTRATHORACIC LYMPH NODES
200.83 OTHER NAMED VARIANTS OF LYMPHOSARCOMA AND RETICULOSARCOMA INVOLVING INTRA-ABDOMINAL LYMPH NODES
200.84 OTHER NAMED VARIANTS OF LYMPHOSARCOMA AND RETICULOSARCOMA INVOLVING LYMPH NODES OF AXILLA AND UPPER LIMB
200.85 OTHER NAMED VARIANTS OF LYMPHOSARCOMA AND RETICULOSARCOMA INVOLVING LYMPH NODES OF INGUINAL REGION AND LOWER LIMB
200.86 OTHER NAMED VARIANTS OF LYMPHOSARCOMA AND RETICULOSARCOMA INVOLVING INTRAPELVIC LYMPH NODES
200.87 OTHER NAMED VARIANTS OF LYMPHOSARCOMA AND RETICULOSARCOMA INVOLVING SPLEEN
200.88 OTHER NAMED VARIANTS OF LYMPHOSARCOMA AND RETICULOSARCOMA INVOLVING LYMPH NODES OF MULTIPLE SITES
202.00 NODULAR LYMPHOMA UNSPECIFIED SITE
202.01 NODULAR LYMPHOMA INVOLVING LYMPH NODES OF HEAD FACE AND NECK
202.02 NODULAR LYMPHOMA INVOLVING INTRATHORACIC LYMPH NODES
202.03 NODULAR LYMPHOMA INVOLVING INTRA-ABDOMINAL LYMPH NODES
202.04 NODULAR LYMPHOMA INVOLVING LYMPH NODES OF AXILLA AND UPPER LIMB
202.05 NODULAR LYMPHOMA INVOLVING LYMPH NODES OF INGUINAL REGION AND LOWER LIMB
202.06 NODULAR LYMPHOMA INVOLVING INTRAPELVIC LYMPH NODES
202.07 NODULAR LYMPHOMA INVOLVING SPLEEN
202.08 NODULAR LYMPHOMA INVOLVING LYMPH NODES OF MULTIPLE SITES
202.10 MYCOSIS FUNGOIDES UNSPECIFIED SITE
202.11 MYCOSIS FUNGOIDES INVOLVING LYMPH NODES OF HEAD FACE AND NECK
202.12 MYCOSIS FUNGOIDES INVOLVING INTRATHORACIC LYMPH NODES
202.13 MYCOSIS FUNGOIDES INVOLVING INTRA-ABDOMINAL LYMPH NODES
202.14 MYCOSIS FUNGOIDES INVOLVING LYMPH NODES OF AXILLA AND UPPER LIMB
202.15 MYCOSIS FUNGOIDES INVOLVING LYMPH NODES OF INGUINAL REGION AND LOWER LIMB
202.16 MYCOSIS FUNGOIDES INVOLVING INTRAPELVIC LYMPH NODES
202.17 MYCOSIS FUNGOIDES INVOLVING SPLEEN
202.18 MYCOSIS FUNGOIDES INVOLVING LYMPH NODES OF MULTIPLE SITES
202.20 SEZARY'S DISEASE UNSPECIFIED SITE
202.21 SEZARY'S DISEASE INVOLVING LYMPH NODES OF HEAD FACE AND NECK
202.22 SEZARY'S DISEASE INVOLVING INTRATHORACIC LYMPH NODES
202.23 SEZARY'S DISEASE INVOLVING INTRA-ABDOMINAL LYMPH NODES
202.24 SEZARY'S DISEASE INVOLVING LYMPH NODES OF AXILLA AND UPPER LIMB
202.25 SEZARY'S DISEASE INVOLVING LYMPH NODES OF INGUINAL REGION AND LOWER LIMB
202.26 SEZARY'S DISEASE INVOLVING INTRAPELVIC LYMPH NODES
202.27 SEZARY'S DISEASE INVOLVING SPLEEN
202.28 SEZARY'S DISEASE INVOLVING LYMPH NODES OF MULTIPLE SITES
202.30 MALIGNANT HISTIOCYTOSIS UNSPECIFIED SITE
202.31 MALIGNANT HISTIOCYTOSIS INVOLVING LYMPH NODES OF HEAD FACE AND NECK
202.32 MALIGNANT HISTIOCYTOSIS INVOLVING INTRATHORACIC LYMPH NODES
202.33 MALIGNANT HISTIOCYTOSIS INVOLVING INTRA-ABDOMINAL LYMPH NODES
202.34 MALIGNANT HISTIOCYTOSIS INVOLVING LYMPH NODES OF AXILLA AND UPPER LIMB
202.35 MALIGNANT HISTIOCYTOSIS INVOLVING LYMPH NODES OF INGUINAL REGION AND LOWER LIMB
202.36 MALIGNANT HISTIOCYTOSIS INVOLVING INTRAPELVIC LYMPH NODES
202.37 MALIGNANT HISTIOCYTOSIS INVOLVING SPLEEN
202.38 MALIGNANT HISTIOCYTOSIS INVOLVING LYMPH NODES OF MULTIPLE SITES
202.40 LEUKEMIC RETICULOENDOTHELIOSIS UNSPECIFIED SITE
202.41 LEUKEMIC RETICULOENDOTHELIOSIS INVOLVING LYMPH NODES OF HEAD FACE AND NECK
202.42 LEUKEMIC RETICULOENDOTHELIOSIS INVOLVING INTRATHORACIC LYMPH NODES
202.43 LEUKEMIC RETICULOENDOTHELIOSIS INVOLVING INTRA-ABDOMINAL LYMPH NODES
202.44 LEUKEMIC RETICULOENDOTHELIOSIS INVOLVING LYMPH NODES OF AXILLA AND UPPER ARM
202.45 LEUKEMIC RETICULOENDOTHELIOSIS INVOLVING LYMPH NODES OF INGUINAL REGION AND LOWER LIMB
202.46 LEUKEMIC RETICULOENDOTHELIOSIS INVOLVING INTRAPELVIC LYMPH NODES
202.47 LEUKEMIC RETICULOENDOTHELIOSIS INVOLVING SPLEEN
202.48 LEUKEMIC RETICULOENDOTHELIOSIS INVOLVING LYMPH NODES OF MULTIPLE SITES
202.50 LETTERER-SIWE DISEASE UNSPECIFIED SITE
202.51 LETTERER-SIWE DISEASE INVOLVING LYMPH NODES OF HEAD FACE AND NECK
202.52 LETTERER-SIWE DISEASE INVOLVING INTRATHORACIC LYMPH NODES
202.53 LETTERER-SIWE DISEASE INVOLVING INTRA-ABDOMINAL LYMPH NODES
202.54 LETTERER-SIWE DISEASE INVOLVING LYMPH NODES OF AXILLA AND UPPER LIMB
202.55 LETTERER-SIWE DISEASE INVOLVING LYMPH NODES OF INGUINAL REGION AND LOWER LIMB
202.56 LETTERER-SIWE DISEASE INVOLVING INTRAPELVIC LYMPH NODES
202.57 LETTERER-SIWE DISEASE INVOLVING SPLEEN
202.58 LETTERER-SIWE DISEASE INVOLVING LYMPH NODES OF MULTIPLE SITES
202.60 MALIGNANT MAST CELL TUMORS UNSPECIFIED SITE
202.61 MALIGNANT MAST CELL TUMORS INVOLVING LYMPH NODES OF HEAD FACE AND NECK
202.62 MALIGNANT MAST CELL TUMORS INVOLVING INTRATHORACIC LYMPH NODES
202.63 MALIGNANT MAST CELL TUMORS INVOLVING INTRA-ABDOMINAL LYMPH NODES
202.64 MALIGNANT MAST CELL TUMORS INVOLVING LYMPH NODES OF AXILLA AND UPPER LIMB
202.65 MALIGNANT MAST CELL TUMORS INVOLVING LYMPH NODES OF INGUINAL REGION AND LOWER LIMB
202.66 MALIGNANT MAST CELL TUMORS INVOLVING INTRAPELVIC LYMPH NODES
202.67 MALIGNANT MAST CELL TUMORS INVOLVING SPLEEN
202.68 MALIGNANT MAST CELL TUMORS INVOLVING LYMPH NODES OF MULTIPLE SITES
202.70 PERIPHERAL T CELL LYMPHOMA, UNSPECIFIED SITE, EXTRANODAL AND SOLID ORGAN SITES
202.71 PERIPHERAL T CELL LYMPHOMA, LYMPH NODES OF HEAD, FACE, AND NECK
202.72 PERIPHERAL T CELL LYMPHOMA, INTRATHORACIC LYMPH NODES
202.73 PERIPHERAL T CELL LYMPHOMA, INTRA-ABDOMINAL LYMPH NODES
202.74 PERIPHERAL T CELL LYMPHOMA, LYMPH NODES OF AXILLA AND UPPER LIMB
202.75 PERIPHERAL T CELL LYMPHOMA, LYMPH NODES OF INGUINAL REGION AND LOWER LIMB
202.76 PERIPHERAL T CELL LYMPHOMA, INTRAPELVIC LYMPH NODES
202.77 PERIPHERAL T CELL LYMPHOMA, SPLEEN
202.78 PERIPHERAL T CELL LYMPHOMA, LYMPH NODES OF MULTIPLE SITES
202.80 OTHER MALIGNANT LYMPHOMAS UNSPECIFIED SITE
202.81 OTHER MALIGNANT LYMPHOMAS INVOLVING LYMPH NODES OF HEAD FACE AND NECK
202.82 OTHER MALIGNANT LYMPHOMAS INVOLVING INTRATHORACIC LYMPH NODES
202.83 OTHER MALIGNANT LYMPHOMAS INVOLVING INTRA-ABDOMINAL LYMPH NODES
202.84 OTHER MALIGNANT LYMPHOMAS INVOLVING LYMPH NODES OF AXILLA AND UPPER LIMB
202.85 OTHER MALIGNANT LYMPHOMAS INVOLVING LYMPH NODES OF INGUINAL REGION AND LOWER LIMB
202.86 OTHER MALIGNANT LYMPHOMAS INVOLVING INTRAPELVIC LYMPH NODES
202.87 OTHER MALIGNANT LYMPHOMAS INVOLVING SPLEEN
202.88 OTHER MALIGNANT LYMPHOMAS INVOLVING LYMPH NODES OF MULTIPLE SITES
202.90 OTHER AND UNSPECIFIED MALIGNANT NEOPLASMS OF LYMPHOID AND HISTIOCYTIC TISSUE UNSPECIFIED SITE
202.91 OTHER AND UNSPECIFIED MALIGNANT NEOPLASMS OF LYMPHOID AND HISTIOCYTIC TISSUE INVOLVING LYMPH NODES OF HEAD FACE AND NECK
202.92 OTHER AND UNSPECIFIED MALIGNANT NEOPLASMS OF LYMPHOID AND HISTIOCYTIC TISSUE INVOLVING INTRATHORACIC LYMPH NODES
202.93 OTHER AND UNSPECIFIED MALIGNANT NEOPLASMS OF LYMPHOID AND HISTIOCYTIC TISSUE INVOLVING INTRA-ABDOMINAL LYMPH NODES
202.94 OTHER AND UNSPECIFIED MALIGNANT NEOPLASMS OF LYMPHOID AND HISTIOCYTIC TISSUE INVOLVING LYMPH NODES OF AXILLA AND UPPER LIMB
202.95 OTHER AND UNSPECIFIED MALIGNANT NEOPLASMS OF LYMPHOID AND HISTIOCYTIC TISSUE INVOLVING LYMPH NODES OF INGUINAL REGION AND LOWER LIMB
202.96 OTHER AND UNSPECIFIED MALIGNANT NEOPLASMS OF LYMPHOID AND HISTIOCYTIC TISSUE INVOLVING INTRAPELVIC LYMPH NODES
202.97 OTHER AND UNSPECIFIED MALIGNANT NEOPLASMS OF LYMPHOID AND HISTIOCYTIC TISSUE INVOLVING SPLEEN
202.98 OTHER AND UNSPECIFIED MALIGNANT NEOPLASMS OF LYMPHOID AND HISTIOCYTIC TISSUE INVOLVING LYMPH NODES OF MULTIPLE SITES
203.00 MULTIPLE MYELOMA, WITHOUT MENTION OF HAVING ACHIEVED REMISSION
203.01 MULTIPLE MYELOMA IN REMISSION
203.02 MULTIPLE MYELOMA, IN RELAPSE
203.10 PLASMA CELL LEUKEMIA, WITHOUT MENTION OF HAVING ACHIEVED REMISSION
203.11 PLASMA CELL LEUKEMIA IN REMISSION
203.12 PLASMA CELL LEUKEMIA, IN RELAPSE
203.80 OTHER IMMUNOPROLIFERATIVE NEOPLASMS, WITHOUT MENTION OF HAVING ACHIEVED REMISSION
203.81 OTHER IMMUNOPROLIFERATIVE NEOPLASMS IN REMISSION
203.82 OTHER IMMUNOPROLIFERATIVE NEOPLASMS, IN RELAPSE
205.10 CHRONIC MYELOID LEUKEMIA, WITHOUT MENTION OF HAVING ACHIEVED REMISSION
205.12 CHRONIC MYELOID LEUKEMIA, IN RELAPSE
259.2 CARCINOID SYNDROME
289.9 UNSPECIFIED DISEASES OF BLOOD AND BLOOD-FORMING ORGANS
For J9216 (Interferon gamma-1B):
288.1 FUNCTIONAL DISORDERS OF POLYMORPHONUCLEAR NEUTROPHILS
Documentation Requirements
• Medical record documentation maintained by the ordering/referring physician must substantiate the medical necessity for the use of the specific Interferon by indicating the condition for which it is being administered.
• The drug name, dosage, and route of administration must also be recorded. This information is normally found in the office/progress notes or medication administration record.
Treatment Logic
• Interferons are naturally occurring small proteins with both antiviral and antiproliferative properties.
o Interferons exert their cellular effects by binding to specific membrane receptors on the cell surface and subsequently initiate a complex sequence of intracellular events.
• Interferon alfacon-1 is a recombinant non-naturally occurring type-1 interferon.
o Interferon alfa-2B is sterile protein product produced by recombinant DNA techniques.
o The exact mechanism of action is unknown, but appears to involve direct antiproliferative action against tumor cells or viral cells to inhibit replication, modulation of the host immune response by enhancing the phagocytic activity of macrophages, and augmentation of specific cytotoxicity of lymphocytes for target cells.
• Alfa-N3 is a naturally occurring antiviral agent derived from human leukocytes.
o It attaches to membrane receptors and causes cellular changes, including increased protein synthesis. Gamma-1B, a biological response modifier, is a single-chain polypeptide containing 140 amino acids.
Sources of Information and Basis for Decision
The Association of Community Cancer Centers. (2006). Compendia-Based Drug Bulletin, February 2006 Update. [On-line]. Available: http://www.accc-cancer.org/
Physician Desk Reference (2004). Montvale, NJ: Medical Economics Company, Inc.
Thevenot, T., Regimbeau, C., Ratziu, V., Leroy, V., Opolon, P., Poynard, T. (2001) Meta-analysis of interferon randomized trials in the treatment of viral hepatitis C in naïve patients: 1999 update. Hepatology, 1, 45-62.
United States Pharmacopeia Drug Information (USPDI). (2006). Oncology Online for Health Care Professionals. Micromedex, Inc. Available: http://www.thomsonhc.com/home/dispatch
10/01/2011
The official local coverage determination (LCD) is the version on the Medicare coverage database at www.cms.gov/medicare-coverage-database/.
AMA CPT / ADA CDT Copyright Statement
CPT codes, descriptions and other data only are copyright 2011 American Medical Association (or such other date of publication of CPT). All Rights Reserved. Applicable FARS/DFARS Clauses Apply. Current Dental Terminology, (CDT) (including procedure codes, nomenclature, descriptors and other data contained therein) is copyright by the American Dental Association. © 2002, 2004 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.
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